What are the treatment options for osteopenia?

Treatment Options for Osteopenia

For patients with osteopenia, first-line treatment should include lifestyle modifications, calcium and vitamin D supplementation, with pharmacologic therapy reserved for those with higher fracture risk based on FRAX assessment or additional risk factors.

Assessment and Risk Stratification

Osteopenia is defined as a bone mineral density (BMD) T-score between -1.0 and -2.5, as measured by dual-energy X-ray absorptiometry (DEXA). While not a disease itself, osteopenia represents decreased bone density that may progress to osteoporosis if not addressed 1.

Risk Assessment:

• FRAX calculation is recommended to determine 10-year fracture risk 2
• Pharmacologic treatment thresholds:
  • 10-year risk of major osteoporotic fracture ≥20%
  • 10-year risk of hip fracture ≥3% 2
  • History of fragility fracture 2

Non-Pharmacologic Interventions

Lifestyle Modifications:

1. Exercise:

   • Regular weight-bearing and muscle-strengthening exercises 2
   • Balance training to prevent falls 2

2. Nutrition:

   • Calcium intake:
     • Ages 19-50: 1,000 mg daily
     • Ages 51-70 (men): 1,000 mg daily
     • Ages 51+ (women) and 71+ (all): 1,200 mg daily 2
   • Vitamin D intake:
     • Ages 19-70: 600 IU daily
     • Ages 71+: 800 IU daily 2
     • Target serum vitamin D level: 20 ng/mL (50 nmol/L) 2

3. Lifestyle Habits:

   • Smoking cessation 2
   • Limiting alcohol consumption 2
   • Fall prevention strategies 2

Pharmacologic Interventions

Pharmacologic therapy is not automatically indicated for all patients with osteopenia. Treatment decisions should be based on fracture risk assessment rather than BMD alone 3, 4.

When to Consider Medication:

• FRAX score exceeds treatment thresholds (≥20% for major osteoporotic fracture or ≥3% for hip fracture) 2
• History of fragility fracture 2
• Additional risk factors such as:
  • Long-term glucocorticoid therapy 5
  • Hypogonadism or premature menopause 2
  • Cancer treatments that cause bone loss 2

Medication Options (when indicated):

1. Bisphosphonates (first-line):

   • Oral options: alendronate, risedronate
   • IV options: zoledronic acid, ibandronate 2
   • Most cost-effective for osteopenic patients with elevated fracture risk 3

2. Denosumab:

   • Alternative for those who cannot tolerate bisphosphonates 2

3. Selective Estrogen Receptor Modulators (SERMs):

   • Raloxifene - good option for younger postmenopausal women 2
   • Avoid in patients with history of thromboembolic events

4. Hormone Therapy:

   • Generally avoided in patients with hormone-responsive cancers 2
   • May be considered for postmenopausal women without contraindications 6

Special Populations

Cancer Patients:

• More aggressive monitoring (BMD every 1-2 years) 2
• Consider earlier intervention, especially with aromatase inhibitors, androgen deprivation therapy, or chemotherapy-induced ovarian failure 2

Inflammatory Bowel Disease:

• Calcium and vitamin D recommended if T-score <-1.5 2
• Address underlying disease activity 2

Liver Transplant Recipients:

• Annual BMD screening for those with pre-existing osteopenia
• Calcium, vitamin D, and weight-bearing exercise 2

Monitoring

• Repeat BMD testing every 2 years for patients with osteopenia 2
• More frequent monitoring (12-24 months) for patients on medications that accelerate bone loss 2
• Assess treatment adherence and effectiveness

Common Pitfalls

1. Treating based on T-score alone without considering overall fracture risk
2. Overlooking secondary causes of bone loss (e.g., vitamin D deficiency, hyperparathyroidism)
3. Inadequate calcium and vitamin D supplementation
4. Failing to address modifiable risk factors before initiating pharmacologic therapy
5. Not recognizing that most fractures occur in the osteopenic range, not in those with osteoporosis 3

By following this approach, clinicians can appropriately identify and treat patients with osteopenia who are at higher risk for fractures while avoiding unnecessary medication in those at lower risk.